Healthcare Provider Details

I. General information

NPI: 1063719490
Provider Name (Legal Business Name): SHANAY LUCIOUS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 01/05/2025
Certification Date: 01/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 4732
LONG BEACH CA
90804-0732
US

IV. Provider business mailing address

PO BOX 4732
LONG BEACH CA
90804-0732
US

V. Phone/Fax

Practice location:
  • Phone: 657-243-0711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125844
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: